Maternal and child nutrition services associated with nutritional knowledge and practices, India

Abstract Objective To evaluate whether maternal and child nutrition activities provided through the Indian Integrated Child Development Services scheme in India were associated with improved nutritional knowledge and practices among beneficiary women. Methods We used a multistage sampling design to randomly select 4400 pregnant women or mothers of children younger than 2 years for a cross-sectional telephone survey. The respondents were beneficiaries of the scheme from across 11 Indian states. We used multivariate regression models controlling for sociodemographic factors to estimate the association between: scheme activities and nutrition messages heard; and scheme activities and nutrition practices. We also estimated the proportion of the total association with nutrition practices which was mediated by nutrition messages. Results Among 110 regression models testing unique pairs of seven activities and 18 nutrition messages, 103 showed a statistically significant positive relationship (median risk ratio, RR: 1.14). For activities and nine nutrition practices, 39 out of 54 tested pairs were significantly associated (median RR: 1.16). We observed statistically significant mediation through nutrition messages for 28 out of 42 tested pairs of activities and nutrition practices. Conclusion Receipt of the scheme’s activities was associated with improved nutrition knowledge and practices. Improvements in practices were statistically mediated by improvements in knowledge. These findings suggest that a large-scale nutrition scheme with a strong counselling component could successfully change beneficiary behaviours.


Introduction
Undernutrition is a major challenge in India.In 2019-2021, an estimated 35.5% of children younger than 5 years were stunted, 19.3% were wasted and 67.1% were anaemic. 1 Among women of reproductive age, an estimated 57.0% were anaemic. 1 Evidence shows that appropriate nutrition practices reduce the prevalence of undernutrition. 2However, in India appropriate nutrition practices could be considerably improved.For example, in 2019-2021, an estimated 36.3% of children younger than 6 months were not exclusively breastfed, 54.1% of children aged 6-8 months were not receiving solid or semisolid food and breast milk, and 88.7% of children aged 6-23 months were not receiving an adequate diet. 1 Additionally, an estimated 55.9% of women did not consume iron-folic acid for 100 days or more during their last pregnancy. 1he Integrated Child Development Services scheme (hereafter the scheme), delivered by the Indian Ministry of Women and Child Development, is a national nutrition programme that aims to reduce maternal and child undernutrition. 3he scheme delivers six core activities: nutrition and health education; supplementary nutrition; growth monitoring and promotion; pre-school non-formal education; immunization; and health referral services.In 2018, the Prime Minister's Overarching Scheme for Holistic Nourishment (POSHAN Abhiyaan) introduced new initiatives to the scheme. 4The new initiatives were: use of a mobile phone-based information technology tool, called ICDS-CAS; capacity-building of the scheme's frontline Anganwadi workers; community mobilization and nutrition behaviour change communication; performance-based incentives for Anganwadi workers; and multisectoral action planning.The theory of change postulates that for the scheme's activities to affect child health outcomes, they must first reach the beneficiaries.These activities can then either directly influence nutritional outcomes, like through nutrition supplementation; or indirectly by enhancing knowledge, which is then presumed to translate into improved practices (Fig. 1).
Approximately 1.4 million Anganwadi workers deliver a set of complementary activities to over 80 million beneficiaries, including both pregnant and lactating women as well as children aged 0-6 years. 5During home visits, Anganwadi workers provide nutrition counselling to pregnant and lactating women. 6These visits are scheduled according to a standardized home visit planner; Anganwadi workers should make a total of 13 home visits during pregnancy and the first 6 months postpartum.Furthermore, they deliver supplemental feedings, known as take-home rations, to pregnant and lactating women and children aged 7 months to 3 years, every two to four weeks.Take-home rations comprise a variety of products, dry rations and hot cooked meals, depending on the implementation locality. 7Beneficiaries should visit Anganwadi centres on a monthly basis for planned growth monitoring and promotion visits for children. 8During these visits, Anganwadi workers identify malnourished children and provide counselling to caregivers on appropriate feeding practices.The Anganwadi centres also provide pre-school education to children aged 3-6 years. 5Immunization and health referral activities pri-marily occur through monthly village health nutrition and sanitation days at the Anganwadi centre or at the subhealth centre.The local government health personnel support these days. 5revious studies have assessed nutritional outcomes of participants of the scheme.Three studies suggest that nutritional outcomes have not improved among beneficiaries, [9][10][11] while another study suggests that service utilization is linked to improved weight for age. 12One nationally representative study noted that beneficiaries had more diverse diets relative to a control group. 11From an implementation perspective, to discern why activities might not lead to improved nutrition, it is essential to understand the intermediary steps involving nutritional knowledge and practices.We therefore aimed to estimate the association of all major nutritional activities delivered through the scheme (under the enhanced POSHAN Abhiyaan approach) to pregnant and lactating mothers and their children with nutrition knowledge and practices among the beneficiaries.We also assessed statistical mediation of improved knowledge on practices.

Methods
Between 6 March and 22 April 2021, we conducted a cross-sectional telephone survey.The survey was telephonic due to the ongoing coronavirus disease 2019 (COVID-19) pandemic.We interviewed scheme beneficiaries, residing in one of the 11 states designated as priority states by the Indian government under POSHAN Abhiyaan, who were either pregnant or had children younger than two years.These states were Andhra Pradesh, Bihar, Chhattisgarh, Gujarat, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Rajasthan, Tamil Nadu and Uttar Pradesh.These 11 states account for 82% of the scheme's total beneficiaries.
All beneficiaries were enrolled in activities at an Anganwadi centre.The centres adapted the activities to the COVID-19 pandemic context: centres were closed in most states, and Anganwadi workers were instead performing home visits twice per month to deliver counselling and take-home rations.Group education and service delivery activities varied by state; they were either discontinued or conducted with limited participation.Despite these changes, the recall period used for this survey (either one month or one year, depending on the service) encompasses a period where all activities were available.
We used a multistage cluster sampling design at the district and Anganwadi centre levels for participant selection (detailed methods are available in the online repository). 13Once Anganwadi centres were selected, beneficiaries were contacted using computer-assisted simple random selection until the prespecified sample size of 4400 participants (400 per state) was reached.

Data collection
Data collection tools included questions on beneficiary sociodemographic information, scheme activities received, nutrition messages that the beneficiary had heard and their nutrition practices.We designed questions on nutrition practices to match the language used in prior national surveys to ensure consistency. 14,15In alignment with World Health Organization (WHO) guidance,

Supplemental nutrition
Delivered through take-home rations for pregnant and lactating mothers, and through school supplemental nutrition for preschool children participants self-reported nutrition practices. 16Using a computer-assisted telephonic interview platform, female interviewers conducted the survey in six local languages: Gujarati, Hindi, Kannada, Marathi, Tamil, and Telugu.A description of training and quality assurance measures is available in the online repository. 13e collected sociodemographic variables and categorized them in alignment with India's National Family and Health Survey. 1 In the analysis, we used seven sociodemographic indicators: age at time of interview; age at time of marriage; highest year of education achieved; religion; caste or tribe; whether the household has a below poverty line card; and number of children.We did not attempt to assess the gender of the participants, nor the sex of the children.Further information is available in the online repository. 13e asked the respondents how many days' worth of take-home rations they had received in the past month.A binary variable was calculated to indicate those respondents who had received 21 days or more worth of rations.Interviewers asked all women whether they had received nutrition information from an Anganwadi worker during their pregnancy, and pregnant women were asked if an Anganwadi worker had visited their home in the past month.Respondents were asked whether they had ever attended a community-based event, which is a group celebration of milestones in the mother or child's life which includes nutrition messages.They were also queried if they had attended a village health sanitation and nutrition day in the past month.This monthly event at the Anganwadi centre focuses on delivery of basic activities such as vaccinations and health information.The mothers were also asked whether they had taken their child for growth monitoring (linked to nutrition messages on infant and young child feeding) in the past year.Finally, we used a binary variable to indicate respondents who lived in districts where the mobile application ICDS-CAS was under implementation.

Health referral services
We asked all respondents what nutrition messages they had previously heard, and they were prompted with a list of key messages that are included in the scheme's nutrition counselling curriculum.Respondents were asked if they had ever received each nutrition message; we did not assess the frequency, timing and context in which they had received the message.We used binary variables to indicate respondents who had received the message.For the purposes of this analysis, nutrition messages received by participants are used to indicate nutrition knowledge.
7][18][19] We calculated the following indicators: consumption of 100 or more days' of iron-folic acid supplements during the last pregnancy; achievement of the minimum dietary diversity among pregnant women; breastfeeding in the first hour of life; exclusive breastfeeding among children younger than 6 months; consumption of solid, semi-solid or soft food and breast milk among children aged 6-8 months; minimum dietary diversity, minimum meal frequency and minimum acceptable diet among children aged 6-23 months; and whether the mother increased food or breastfeeding quantity after a child's illness.

Data analysis
We used Stata software, version 15 (StataCorp LLC., College Station, United States of America) to analyse data.To account for state population size (projected 2021 population among women aged 15-49 years), 20 we weighted point estimates.We corrected confidence intervals (CIs) to account for the clustered sampling design, finite population sampling and stratification.
We calculated proportions for sociodemographic variables, scheme activities, nutrition messages received and nutrition practices.Using Poisson regressions with robust standard errors, 21 we calculated risk ratios (RRs) for (i) the association between activities and nutrition messages received; and (ii) the association between activities and nutrition practices.To estimate the proportion of the total direct effect between activities provided and nutrition practices which are mediated by nutrition messages received, we conducted mediation analyses. 22To summarize the contribution of activities across multiple messages and practices, median RRs and median proportions mediated were calculated.A description of the regression models, mediation algorithm, and handling of missing data is available in the online repository. 13 considered P-values below 0.05 statistically significant.

Ethical considerations
The Ministry of Women and Child Development, Government of India granted permission to conduct the study.We obtained verbal informed consent from each participant before the interview.Considerations related to confidentiality and participant risk are presented in the online repository. 13

Results
Out of 880 Anganwadi centres selected for sampling, beneficiary contact information was received for 745 (84.7%) centres.We obtained phone numbers for 20 244 beneficiaries, of which 16 145 were selected for contact using computerassisted simple random selection.Of those selected, 8874 (55.0%) had phones that were unreachable, leaving 7271 available contacts.Among those successfully contacted, 995 were incorrect numbers, 1258 were not available for interview, 454 were no longer eligible for the survey and 164 refused to participate.The final sample size was 4400 respondents.
The sample population was relatively young, with 81.8% (after population weighting) of respondents being between 20 and 29 years old at the time of interview.The majority (53.0%) of respondents got married before the age of 20 years.Many participants were from disadvantaged backgrounds, including 53.2% living in households with a below-poverty line card; 31.0%from scheduled castes or tribes; and 19.6% of respondents having only primary school education (Table 1).
The most frequently reported service received in the past year was growth monitoring and promotion activities (Table 2; weighted 73.7%).Sixty-two percent of respondents indicated that they had received nutrition information from the Anganwadi worker during pregnancy.About half of the respondents (55.4%) had received more than 21 days' worth of take-home rations.Group events, such as communitybased events and village health sanitation and nutrition days, were the activities least frequently reported.
Core scheme messages (i.e.consumption of iron-folic acid after dinner during pregnancy; consumption of green and yellow/orange fruits and vegetables during pregnancy; breast- The most common nutrition practice was exclusive breastfeeding in the first 6 months of life (81.0%;95% CI: 76.6 to 84.7).The least common practice was the achievement of a minimum acceptable diet for children aged 6 to 23 months (26.3%; 95% CI: 23.0 to 30.0).Achievement of the minimum diet diversity was considerably higher among pregnant women (67.4%; 95% CI: 63.0 to 71.6) than among children aged 6 to 23 months (35.6%; 95% CI: 31.8 to 39.6).Approximately two out of five women did not consume more than 100 days' worth of iron-folic acid tablets during pregnancy, and a similar proportion did not initiate complemen-tary feeding when their baby reached 6 months of age.Relative to most of the practices, increasing the quantity of food or breastfeeding following an illness was practiced by fewer respondents (41.5%; 95% CI: 37.8 to 45.3; Table 2).
After controlling for potential sociodemographic confounders, the receipt of scheme activities was frequently associated with having heard key nutrition messages.Among 110 regression models testing unique pairs of activities and messages, 103 showed a statistically significant positive relationship (Table 3).Among the seven activities, relatively strong associations were observed (with nutrition messages received as the outcome) for growth monitoring (median RR: 1.30); nutrition information received during pregnancy (median RR: 1.25); and having ever attended a community-based event (median RR: 1.19; available in the online repository). 13More specific nutrition messages (which were heard by a relatively smaller proportion of respondents) typically showed larger improvements associated with the receipt of activities.For example, across all the relevant activities that were tested, the median RR was above 1.20 for the following messages: take one iron-folic acid tablet daily for at least 100 days during pregnancy; non-vegetarians should include non-vegetarian items in the diet; from 9-11 months of age, the child should be fed three bowls of complementary food daily; from 12-24 months of age, the child should be fed four bowls of complementary food daily; after a child's illness, increase the quantity of food fed (online repository). 13egarding the association between activities provided and nutrition practices, a statistically significant positive association was observed among 39 out of 54 tested service-practice pairs (Table 4).Information received from the Anganwadi worker during pregnancy demonstrated the strongest association with practices (median RR: 1.32; available in the online repository). 13aving attended a community-based event and having received growth monitoring in the past year were also associated with substantial impacts (median RR: 1.21 for both activities). 13cross all seven activities, the nutrition practices that were associated with the largest improvements were minimum acceptable diet (median RR: 1.69); and minimum dietary diversity (median Nutrition services and nutritional knowledge and practices, India Christopher T Andersen et al. RR: 1.63) among children.Appropriate pregnancy diet practices (iron-folic acid consumption for more than 100 days and achievement of the minimum dietary diversity) were also significantly higher among service recipients (median RR: 1.23).
The association between community-based events and all seven nutrition practices was significantly mediated via nutrition messages (median proportion mediated: 18.7%; P-values < 0.01 for all seven practices; Table 5 and online repository). 13For nutrition informa-tion from Anganwadi workers during pregnancy, significant mediation by nutrition messages was seen for six out of seven nutrition practices (median proportion mediated: 20.9%; P-values < 0.01 for six out of seven practices; Table 5 and online repository). 13

Scheme activity
Take-home ration received for 21 days or more in the past month b (n = all 4400 participants) 55. 4    a Take-home rations comprise of a variety of products, dry rations and hot cooked meals, depending on the implementation locality.
b Missing data for the number of days of take-home rations for nine pregnant women, 39 women with children aged 0-5 months, and 51 women with children aged 6-23 months.

Discussion
This study of pregnant women and mothers of young children enrolled in the Integrated Child Development Services scheme suggests that one of the world's largest nutrition programmes may be effectively improving beneficiary knowledge and practices.A positive association was consistently observed between seven scheme activities and a range of nutrition knowledge and nutrition practice indicators.Furthermore, a statistically significant proportion of the association between several activities and nutrition practices was mediated by knowledge.Three activities showed a greater advantage for the beneficiaries: receipt of nutrition information from Anganwadi workers during pregnancy; participation in community-based events; and receipt of growth monitoring activities.
In 2015-2016, 71.8% of scheme beneficiaries reported having received health and nutrition counselling in pregnancy, 15 which is higher than our estimate of 62.3%.This result could be explained by the fact that we conducted the study when the COVID-19 pandemic greatly burdened India.Group events, such as community-based events and village health sanitation and nutrition days, were reduced and modified during the pandemic, which could explain why the respondents used these activities the least.While this result suggests that COVID-19 may have somewhat constrained the delivery of activities, the overall service delivery levels across all indicators remained relatively strong given the challenging operational conditions.
Nutrition activities that include a strong component of nutritional messaging were associated with the largest impacts on both nutrition knowledge and practices.Anganwadi workers are trained to provide a holistic curriculum of nutrition messages to beneficiaries during pregnancy and during the first two years of their children's life.Other activities that do not include a strong interactive counselling component, such as delivery of take-home rations and attendance at village health sanitation and nutrition days, were less associated with improved knowledge or practices.The modest associations between use of the mobile-based application and nutrition knowledge and practices may have been due to ongoing problems with the application's functionality.
All of the nutrition messages examined in this study had been heard by more than three out of five beneficiaries, which represents an important reach of the scheme.Messages which had been heard by a lower proportion of beneficiaries tended to have larger improvements associated with activities.This result reinforces the importance of scheme service delivery for enhancing these lagging messages.
Having heard relevant nutrition messages was a statistically significant mediator of improved nutrition practices.The linkage between nutrition knowledge and practice is an underlying assumption of nutrition education programmes.However, knowledge is necessary but not sufficient to drive behaviour change. 23In this study, the proportion of the total effect mediated was relatively low, which could be explained by several potential factors, such as how knowledge was measured and included in the statistical models (further explanation in online repository). 13 large meta-analysis found that social mobilization and behaviour change communication were linked to a 73% increase in the odds of exclusive breastfeeding, but no statistically significant impacts on early initiation of breastfeeding, minimum dietary diversity or minimum meal frequency. 24By contrast, the 63% median increase in child dietary diversity and 69% median increase in minimum acceptable diet associated with scheme activities in this study are considerable.Although the association of scheme activities with exclusive breastfeeding in this study are smaller than that reported in the meta-analysis, the high overall prevalence of exclusive breastfeeding in the present study provides a mathematical constraint to the magnitude of the RR.Another review, which primarily included randomized controlled trials, found that breastfeeding counselling was associated with a 20% increase in the early initiation of breastfeeding. 25The increases in early initiation of breastfeeding associated with counselling-intensive activities in the present study are similar in magnitude to those reported in the review.The evidence from this study therefore suggests that effects in largescale programmes could potentially attain the effects seen in the typically smaller, more controlled settings of interventional research.
This study has limitations.For the safety of study participants and research personnel in the context of high COVID-19 transmission, data for this study were collected by telephone.Hence, collecting anthropometric or hematologic indicators of nutritional status was impossible.However, a large body of evidence supports the fact that improvements in infant and young child feeding practices are linked to better health outcomes. 26We therefore believe it is plausible to expect that the improvements in nutrition practices observed in this study would result in some improvement in child outcomes.
The potential for confounding and measurement error should be considered when interpreting the results of this study.As for all observational research, there exists a risk of unmeasured confounding.To reduce bias in the estimates of the association between nutrition activities and knowledge or practices, we statistically controlled for seven socioeconomic variables.However, one or multiple unmeasured confounders might exist, which could bias our reported associations.Participants self-reported service receipt, nutrition knowledge and practices, which could result in misclassification due to inaccurate recall.If misclassification of the exposure and outcome are independent in a given model, then the RR would be biased towards the null.The reader should therefore be duly prudent when considering the causal implications of these findings.Other potential limitations, such as the use of a cross-sectional design and telephonic data collection, are presented in the online repository. 13n India, improved nutrition practices can likely be achieved through expansion and intensification of access to counselling-intensive interventions through the Integrated Child Development Services scheme.Since knowledge is a mediator of improved practices, the scheme may consider focusing on increasing the dissemination of messages and ensuring that beneficiary recall and comprehension of the messages is firm.Policy-makers worldwide may use the data presented here to adapt aspects of the scheme's activities that are appropriate for other contexts, as the evidence suggests the scheme has yielded benefits for nutrition knowledge and practices among beneficiaries.

Fig. 1 .
Fig. 1.Theory of change linking activities of the Integrated Child Development Services scheme to child nutritional outcomes, India lactating women; children younger than 6 years) Bull World Health Organ 2024;102:9-21| doi: http://dx.doi.org/10.2471/BLT.22.289129Nutrition services and nutritional knowledge and practices, India Christopher T Andersen et al.
Scheme activityTake-home ration received for 21 days or more in the past month b (n = all 4400 participants) 55.4 (50.5 to 60.1) Information on nutrition received from an Anganwadi worker during pregnancy (n = all 4400 participants) 62.3 (58.5 to 66.1) Anganwadi worker visited the home in the past month (n = 1100 pregnant women) 65.5 (60.6 to 70.0) Ever attended a community-based event (n = all 4400 participants) 41.4 (38.2 to 44.6) Attended a village health nutrition and sanitation day in the past month (n = all 4400 participants) 45.7 (42.3 to 49.3) Growth monitoring for child received in the past year (n = 3300 mothers of children aged 0-23 months) 73.7 (70.2 to 76.9) Application used by Anganwadi workers in the district c (n = all 4400 participants) 60.6 (57.0 to 64.1) Messages received about pregnancy nutrition (n = 1100 pregnant women)Take one iron-folic acid tablet at night after dinner 84.4 (80.6 to 87.5) Take one iron-folic acid tablet daily for at least 100 days 65.1 (61.4 to 68.6) Consume green and yellow/orange coloured fruits and vegetables and drink milk daily 93.7 (91.3 to 95.4) Increase the quantity of food during pregnancy 79.2 (76.0 to 82.0)Take frequent meals during the day (five to six small meals rather than three) 86.7 (83.4 to 89.4) Rest for 1 to 2 hours in a day 86.8 (83.9 to 89.3) Non-vegetarians should include non-vegetarian items in the diet 62.1 (58.1 to 66.0) Infant and young child nutrition Feed colostrum immediately after birth (n = 1100 pregnant women) 62.9 (59.0 to 66.7) Breastfeed the baby within 1 hour of birth (n = all 4400 participants) 79.6 (76.5 to 82.4) Exclusive breastfeeding until 6 months of age (n = all 4400 participants) 83.8 (81.1 to 86.1) Initiate complementary feeding at age 6 months, along with breastfeeding (n = 3300 mothers of children aged 0-23 months) 86.5 (83.2 to 89.2) cA community-based event is a group celebration of milestones in the mother or child's life which includes nutrition messages.d Application refers to a common application software of the integrated child development activities.Note: We set integrated child development activities as independent variable and messages received as dependent variable, and adjusted for sociodemographic factors.Bull World Health Organ 2024;102:9-21| doi: http://dx.doi.org/10.2471/BLT.22.289129Nutrition services and nutritional knowledge and practices, India Christopher T Andersen et al.Table 5. Percentage of the association between activities of Integrated Child Development Services scheme and nutrition practice that is explained by having received related nutritional messages, Achieved the minimum dietary diversity for pregnant women (≥ five food groups; n = 1100 pregnant women) 100.0 to 100.0) Breastfeeding initiated in the first hour of life (n = 3300 women with children aged 0-23 months) Bull World Health Organ 2024;102:9-21| doi: http://dx.doi.org/10.2471/BLT.22.289129Nutrition services and nutritional knowledge and practices, India Christopher T Andersen et al.
Nutrition services and nutritional knowledge and practices, India Christopher T Andersen et al.

Table 3 . The association between activities of the Integrated Child Development Services scheme and messages received, India, 2021 Nutrition message Service received, RR (95% CI) Take-home rations for more than 21 days a,b Nutrition information from an Anganwadi worker during pregnancy Home visit by an Anganwadi worker in past month (n = 1100 pregnant women)
Nutrition services and nutritional knowledge and practices, India Christopher T Andersen et al.

message Service received, RR (95% CI) Take-home rations for more than 21 days a,b Nutrition information from an Anganwadi worker during pregnancy Home visit by an Anganwadi worker in past month (n = 1100 pregnant women)
CI: confidence interval; NA: not applicable; RR: risk ratio.a Take-home rations comprise of a variety of products, dry rations and hot cooked meals, depending on the implementation locality.b Missing data for the number of days of take-home rations for nine pregnant women, 39 women with children aged 0-5 months, and 51 women with children aged 6-23 months.c A community-based event is a group celebration of milestones in the mother or child's life which includes nutrition messages.d Application refers to a common application software of the integrated child development activities.Note: We set integrated child development activities as independent variable and messages received as dependent variable, and adjusted for sociodemographic factors.(. ..continued)Bull World Health Organ 2024;102:9-21| doi: http://dx.doi.org/10.2471/BLT.22.289129Nutrition services and nutritional knowledge and practices, India Christopher T Andersen et al.

Table 4 . The association between activities of the Integrated Child Development Services scheme and nutrition practices, India, 2021 Nutrition practice Intervention received, RR (95% CI) Take-home rations for more than 21 days a,b Nutrition information from Anganwadi worker during pregnancy Home visit by an Anganwadi worker
CI: confidence interval; NA: not applicable; RR: risk ratio.